More on the condom conversation

I posted some comments other day about the reaction to Benedict XVI’s remarks regarding the possibility that condom use in Africa might actually be having a negative consequence on the spread of HIV/Aids. Today I read two interesting comments in the continued conversation over the reaction to the Pope’s remarks.

The first of these comments comes from Ross Douthat, currently of <i>The Atlantic</i> and recently announced conservative pundit at the New York Times. Douthat is a conservative Roman Catholic and admits his bias, but makes some interesting observations:

I should note that I don’t pretend to be an expert on this topic, and my own conservative and Catholic biases have no doubt shaped the reading that I’ve done about AIDS-fighting strategies. But it’s my impression – created, in large part, by reading Helen Epstein’s The Invisible Cure (and if there’s a devastating rebuttal to her arguments, please send it my way) – that an awful lot of the money poured into condom-promotion over the years would have much been better spent promoting “partner reduction” in cultures inclined to promiscuity and de facto polygamy instead. This isn’t the same as promoting abstinence exclusively, and indeed, Epstein is witheringly critical of some of the abstinence-only programs that American dollars have funded in the Bush era. But “partner reduction” is a lot more consonant with the Catholic Church’s longstanding position – that it’s better to promote monogamy and fidelity than to take promiscuity as a given and make it as safe as possible – than you’d think from the overheated talk about how the Vatican’s flat-earth position on condoms has cost millions of lives.

What’s more, I have a hard time believing that the public-health and foreign-aid community’s longstanding preference for condom promotion has nothing to do with ideological biases of their own. Yes, the Catholic Church’s conservative position on sexual morality determines which public-health interventions the Vatican willing to support, and limits the willingness of Catholic institutions to simply follow the data wherever it leads. But what’s true of Catholics is true of other groups as well. And when you read Epstein on how slow the AIDS establishment was to acknowledge the importance of partner-reduction – or when you read about Bill Gates getting booed at an international AIDS conference when he mentioned abstinence and fidelity – it’s awfully hard to escape the conclusion that the combination of a liberationist view of sexual ethics and a post-colonial unwillingness to critique existing African patterns of sexual behavior has seriously hampered the international community’s efforts to curb the spread of HIV.

Later in the day, someone emailed me this opinion piece from the Washington Post, written by Edward C. Green, research scientist at the Harvard School of public health. Green writes that the Pope was right about his assertion:

When Pope Benedict XVI commented this month that condom distribution isn’t helping, and may be worsening, the spread of HIV/AIDS in Africa, he set off a firestorm of protest. Most non-Catholic commentary has been highly critical of the pope. A cartoon in the Philadelphia Inquirer, reprinted in The Post, showed the pope somewhat ghoulishly praising a throng of sick and dying Africans: “Blessed are the sick, for they have not used condoms.”

Yet, in truth, current empirical evidence supports him.

We liberals who work in the fields of global HIV/AIDS and family planning take terrible professional risks if we side with the pope on a divisive topic such as this. The condom has become a symbol of freedom and — along with contraception — female emancipation, so those who question condom orthodoxy are accused of being against these causes. My comments are only about the question of condoms working to stem the spread of AIDS in Africa’s generalized epidemics — nowhere else.

In 2003, Norman Hearst and Sanny Chen of the University of California conducted a condom effectiveness study for the United Nations’ AIDS program and found no evidence of condoms working as a primary HIV-prevention measure in Africa. UNAIDS quietly disowned the study. (The authors eventually managed to publish their findings in the quarterly Studies in Family Planning.) Since then, major articles in other peer-reviewed journals such as the Lancet, Science and BMJ have confirmed that condoms have not worked as a primary intervention in the population-wide epidemics of Africa.

[…]

Let me quickly add that condom promotion has worked in countries such as Thailand and Cambodia, where most HIV is transmitted through commercial sex and where it has been possible to enforce a 100 percent condom use policy in brothels (but not outside of them). In theory, condom promotions ought to work everywhere. And intuitively, some condom use ought to be better than no use. But that’s not what the research in Africa shows.

Why not?

One reason is “risk compensation.” That is, when people think they’re made safe by using condoms at least some of the time, they actually engage in riskier sex.

The general consensus seems to be that–in the situation of an epidemic–behavioral changes have to reach a certain point, and to have limited infection to a certain degree before condom use has any measurable impact. This indicates that prophylactics without attendant behavioral changes–including a lessening of promiscuity and a trend toward fewer sexual partners–is not enough.

All of this is to say, no one should assume that it is only the religious who hold opinions religiously or by faith. I long ago discovered that for most people (at least most Americans) their political and cultural views, whether liberal or conservative–even if supposedly secular–are ideological and operate on the same level as religious faith, even to the extent of being irrational.